Provider Demographics
NPI:1124177118
Name:RAND, CARISSA C (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:C
Last Name:RAND
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:SUITE 414
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1868
Mailing Address - Country:US
Mailing Address - Phone:781-952-1433
Mailing Address - Fax:508-630-2462
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 414
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-952-1433
Practice Address - Fax:508-630-2462
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2012-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1656363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP200601Medicare PIN
MAP97822Medicare UPIN